Kusserow’s Corner: Holiday Season is Also a Busy Time for Health Care Enforcement

November kicks off the holiday season with Thanksgiving at the end of the month and the beginning of serious holiday shopping, but it has also been a busy time for the DOJ and OIG in taking enforcement actions. The following are some highlights that reflect the breadth and scope of their work during the first couple of weeks of the month.

The most prominent case early in the month was the settlement with the Johnson & Johnson settlement of more than $2.2 billion for off-label marketing and kickbacks to doctors and pharmacists.

In New York, an orthopedic surgeon pled guilty to operating a long-running health care fraud scheme in which he defrauded Medicare, the New York State Insurance Fund, and numerous private health insurance providers out of over $2.5 million by systematically lying about the nature and scope of the surgical procedures that he performed.

In Louisiana, there were indictments of an owner and marketer of DME supply company and others for billing Medicare more than $3 million for power wheelchairs, wheelchair accessories and orthotic equipment for Medicare beneficiaries who neither wanted nor needed the equipment, as well as paying kickbacks to “marketers” to locate doctors who were willing to prescribe the equipment to Medicare beneficiaries who did not want or need these items.

In Illinois there was a guilty plea for submitting false and fraudulent bills in relation to alleged performance of personal assistant services in the Medicaid Home Services Program.

In Fort Myers, Florida there were guilty pleas for individuals for committing health care fraud at their pharmacy where they submitted claims for prescriptions not filled or provided to beneficiaries and recipients. The claims included prescriptions for patients that had not been written or authorized by any duly licensed physician. In addition, the co-conspirators submitted and caused claims to be submitted for reimbursement from these same programs for beneficiaries and recipients who were deceased.

In Dallas, a woman was convicted at trial for her role in a $3 million, along with other 5 other co-conspirators who were being handled separately. They were involved in a scheme to submit fraudulent claims to Medicare for diagnostic tests and office visits that were not legal.

In Orlando, a hospice agreed to pay $3 Million to resolve allegations of billing for patients not terminally ill.

In Miami, a therapist for a mental-health clinic, was sentenced today to serve 120 months in prison for his participation in a Medicare fraud scheme. The individual had been convicted earlier by trial for causing with co-conspirators the submission of more than $55 million dollars in fraudulent claims to Medicare. The evidence at trial showed that they conducted sham therapy sessions for patients he knew were ineligible for treatment.

In South Florida, a patient broker for a psychiatric hospital was sentenced for her participation in a $67 million Medicare fraud scheme.

In St. Louis, MO a doctor pled guilty to making a false statement to federal agents regarding his purchases of misbranded Botox® from a foreign unlicensed drug wholesaler, some of which had counterfeit exterior packaging.

In McAllen, Texas, two former clinic staffers and a physician assistant’s wife have all been ordered to prison for fraud. They conspired with others to submit false claims to Medicare and Medicaid using the provider number of a medical doctor who for years before his death, was unable to practice medicine as result of Parkinson’s disease and associated dementia.

In New York, the former CEO of a hospital was sentenced for participating in a fraudulent scheme in which he was paid nearly $300,000 in undisclosed kickbacks from a subordinate hospital employee in exchange for negotiating payment of that employee’s annual bonus, as well as making false statements about certain conflicts of interest.

In the Detroit area, a home health agency owner was sentence for his role in a $13.8 million Medicare fraud scheme. Working with co-conspirators, he paid kickbacks to recruiters to obtain Medicare beneficiary information used to bill Medicare for home health services – including physical therapy and skilled nursing services – that were never rendered. In another Detroit case, the owner of a home health care agency was sentenced for her leading role in a $2.2 million Medicare fraud scheme.

In Sacramento, CA, an individual was sentenced for conspiring to commit health care fraud. According to testimony presented at the trial four physician co-defendants that owned and controlled three health care clinics where claims were submitted for treatment never provided and resulted in more than $5 million in fraud.

In Chicago, a physician was arrested after being indicted on federal charges alleging that he illegally dispensing narcotics, Oxycodone and/or Alprazolam.

In Beaumont, Texas, an orthodontist was sentenced for health care fraud by submitting claims for palatal expanders which were never provided to his patients.

In the Southern District of Illinois, a local city trust and county probation officer pled engaging in a scheme to commit health care fraud for submitting false and fraudulent bills in relation to his alleged performance of personal assistant services in the Home Services Program.

In Buffalo, New York, a Jamaican national was indicted for fraudulently receiving Medicaid benefits, claiming US Citizenship while applying for benefits under Social Security numbers assigned to other people.

In Brooklyn, an owner of a medical clinic was sentenced today for her leading role in a $77 million Medicare fraud scheme wherein billing were submitted to Medicare under three corporate names that paid kickbacks to beneficiaries and used their names to bill Medicare for services that were medically unnecessary or never provided.

In Baton Rouge, a doctor was sentence for involvement in two nearly identical schemes to defraud Medicare that involve procuring names and personal information of Medicare beneficiaries that were used for false and fraudulent prescriptions for power wheelchairs and other durable medical equipment for which the Medicare beneficiaries had no medical need. Previously, conspirators were sentenced in the case.

In Kansas, a pharmacist was sentenced substituting a cheaper drug imported from China for the iron sucrose that the FDA has approved for kidney dialysis patients.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.